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Distress from voluntary refusal of food and fluids to hasten death: what is the role of continuous deep sedation?
  1. Mohamed Y Rady1,2,
  2. Joseph L Verheijde2,3
  1. 1Department of Critical Care Medicine, Mayo Clinic Hospital, Phoenix, Arizona, USA
  2. 2Center for Biology and Society, College of Liberal Arts and Sciences, Arizona State University, Tempe, Arizona, USA
  3. 3Department of Physical Medicine and Rehabilitation, Mayo Clinic, Scottsdale, Arizona, USA
  1. Correspondence to Professor Mohamed Y Rady, Department of Critical Care Medicine, Mayo Clinic Hospital, 5777 East Mayo Blvd, Phoenix, AZ 85054, USA; rady.mohamed{at}

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There is a growing trend to practise physician-assisted dying (death) (PAD) under the premise of providing quality palliative care in consensual and non-consensual life-ending situations.1 The WHO envisages palliative care as a comprehensive system of managing pain and distressing symptoms without intending to shorten the end-of-life (EOL) trajectory.1 In assisted dying, the EOL trajectory is shortened to relieve suffering.1 Bundling PAD with palliative care is precarious because PAD: (1) contravenes the Hippocratic principle of ‘do not kill’; (2) transgresses cultural and religious values of some patients, families and healthcare professionals; and (3) violates basic human rights.2

Voluntary refusal of food and fluids (VRFF) is a legal method of PAD, although medical and societal acceptability is uncertain.3 Etkind reported a patient with amyotrophic lateral sclerosis who desired to end life because of mental anguish and fear of unbearable future suffering.4 The patient chose VRFF to hasten death after the onset of bulbar disease progression. In this paper we comment on: (1) unbearable suffering as an indication for PAD; (2) VRFF as a means to hasten death; (3) efficacy of continuous deep sedation (CDS) for optimal control of distress from VRFF; and (4) bundling assisted dying with palliative and hospice care.

Unbearable suffering

When deciding on the use of CDS, severity of suffering is difficult to quantify objectively.5 The interpretation of the adjectives ‘refractory’ and …

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